成人社区获得性单核细胞增生李斯特菌脑膜炎

Community acquired Listeria monocytogenes meningitis in adults

目的单核细胞增生李斯特菌是继肺炎链球菌、脑膜炎奈瑟氏菌之后的成人急性社区获得性细菌性脑膜炎的第三位致病菌。本研究的主要目的是通过分析一组病例数据，了解单核细胞增生李斯特菌脑膜炎危险因素、临床特征、处理策略及其预后。方法前瞻性队列观察研究，分析一家大型临床教学医院急诊科成人急性社区获得性单核细胞增生李斯特菌脑膜炎十年病例（2001-2010）,并将其与同期其他病原体所致的急性细菌性脑膜炎临床特征进行比较。结果纳人研究的有327例成人急性社区获得性细菌性脑膜炎（Ac-ABM），其中15例为单核细胞增生李斯特菌脑膜炎（Lm-ABM）。老年人（RR=3.14；95%CI1.84-5.35）,免疫缺陷者（RR=3.34；95%CI2.08-5.38）和孕妇（AS12.48;95%C73.29-47.39）患Zm-ABM风险明显增高。40%Lm-ABM病例有脑膜炎三联征表现，同样有40%患者至少有一份脑脊液标本符合经典急性细菌性脑膜炎标准。im-ABM经验性抗生素治疗（EAT）不充分率高达86.7%。Lm-ABM病死率为33.3%,不良临床预后率（GOS〈4）为46.7%,两者均显著高于其他病原体所致的急性细菌性脑膜炎（P值分别为0.015和0.009）。结论老年人、免疫功能缺陷者和孕妇罹患急性细菌性脑膜炎时，要考虑感染单核细胞增生李斯特菌可能。单核细胞增生李斯特菌脑膜炎临床表现和脑脊液指标很难与其他急性细菌性脑膜炎相鉴别，且病死率和致残率高，因此，早期经验性抗生素治疗的充分性尤为关键，特别是在老年人、孕妇、免疫缺陷患者这些特殊群体中，抗生素选择要考虑覆盖单核细胞增生李斯特菌。

Objective To study risk factors associated with predisposition to Lrn - ABM in adult patients and to evaluate the clinical features, management and out in this cohort of patients because Listeria monocytogenes （Lm） is the third most common cause of acute community acquired bacterial meningitis （Ac-ABM） ,after Streptococcus pneumoniae and Neisseria meningitides aetiologies. Methods A descriptive, prospective study carried out in a tertiary grade medical center emergency department in Beijing over a 10 -year period. During the study period, 15 patients of Lm - ABM were included. Comparison of episodes of Lm - ABM versus other aetiologies was made. Results Fifteen episodes of Lm - ABM were identified in 327 adult Ac - ABM patients. Three cohorts of individuals were vulnerable to Lm - ABM ： the elderly （ RR =3. 14; 95% CI 1. 84 - 5. 35） , the immunocompromised （RR = 3. 34; 95% CI 2. 08 - 5. 38）,and pregnant women （ RR 12. 48 ; 95% Cl 3. 29 ？47. 39）. The classic triad of fever, neck stiffness, and altered mental status was present in 40% （6 of 15） Lm - ABM patients. Similarly, 40% patients had at least one of cerebrospinal fluid （ CSF） samples with features met the criteria of typical bacterial meningitis. The coverage of empirical antimicrobial therapy was microbiologically inadequate for 13 （86. 7% ） patients. The mortality rate was 33. 3% （5 of 15） , and 7 （46. 7% ） of 15 patients led to an unfavorable outcome （GOS 〈4） , both of which were significantly higher than those in other aetiologies of Ac - ABM （P =0. 015 P =0. 009 respectively） . Conclusions Our study showed the elderly, the immunocompromised patients, and pregnant women predisposed to Ac - ABM most likely to be Listeria monocytogenes aetiology. In contrast with similar previous reports, the current study showed that patients with meningitis due to Listeria monocytogenes did not present with atypical clinical features. A high proportion of patients received empirical antimicrobial therapy that did not cover Listeria monocytogenes. Lm - ABM is still a serious disease that leads to high morbidity and mortality rates. With these important caveats in mind, our findings have implications for clinical practice and food safety policy makers.